Do things really change?

HAYES MARTIN LECI’URE

Do Things Really Change? George A. Sisson, Sr., MD, Chicago, Illinois

The author presents the historical backdrop of the advent of the Am&ican Society of Head and Neck Surgery and the Society of Head and Neck Sur- geons and their paths that hegzin wide apart and which, over the years, have hecome closer, even in- tertwining with the formation of the joint Council for Approval of Advanced Training in Head and Neck Oncologic Surgery in 1974. The future of head and neck oncology and the role the two societies can play are also coMmented on.

I never actually met Dr. Hayes Martin; I never truly had the opportunity. Of course, I wish I might have. I

believe he would have liked me, and I know I would have liked hi. But no matter, his very being greatly influ- enced my life, first while a resident and postgraduate student at BellevueNmv York University and later while a resident and cancer fellow at Manhattan Eye, Ear and Throat Hospital. Consequently, and fortunately for me, it was early in my career that I became aware of the innova- tive and unprecedented approaches to head and neck surgery that were evolving in a cancer hospital only a few blocks north of where I was a resident.

Some of us can remember one hospital hall rumor going around at that time was that Dr. Martin didn’t favor “ENT” doctors; he supposedly had said there was no need for them. A remark like this, though only hear- say, did not endear Dr. Martin to the leaders in otolaryngology despite his many contributions to surgery. I, a budding, enthusiastic junior otolaryngology resident, could neither understand nor appreciate the underlying reason behind this rumor. However, by then I had met Dr. Jack Lore, who had been accepted as a general surgical resident at St. Vincent’s, and Drs. Jack Lewis, Edwin Cocke, and Frank Keim who had taken so-called “observ- ing fellowships” with Dr. Martin. These four young up starts spent many hours at Memorial Hospital, and their visible excitement about what they saw definitely piqued my curiosity.

Eventually, still during my junior year, I found myself sneaking out of the Manhattan Hospital and jogging over to Memorial to attend early morning Thursday head and neck conferences where most current cases were discussed. I watched and listened most respectfully as the master presided; rarely praising, admonishing often, and intermittently tossing out those glorious cryptic remarks to or at the surgical fellows and, when deserved, to or at the referring physicians. Today, having had the luck to

From the Departmeht of Otolaryngology-Head and Neck Surgery, Northwestern University Medical School, Chicago, Illinois.

Requcats for reprints should be addressed to George A. Sin, Sr., MD, The Department of Otolaryngobgy-Head and Neck Surgery, Northwestern University Medical School, 303 East Chicago Avenue, Searle 12-561, Chicago, Illinois 60611.

Presented at the 35th Annual Meeting of the Society of Head and Neck Surgeons, San Francisco, California, May 21-24,1989.

mature for more than a few years, I can better understand his perspectives in this regard. I soon became a persistent peripatetic undercover observer of Dr. Martin in both clinics and the operating arena, and it quickly became obvious to me, a young trainee in otolaryngology, that otolaryngologists were not well trained, nor were they being well trained, to undertake the originative procedures Dr. Martin was pioneering for the control and cure of head and neck cancers.

From the start it was apparent that a fascinating and challenging head and neck field was developing right before my eyes. Turf battles were certain to rise. This area did become a no man’s land eventually, and competency was not always the standard for control. I am speaking now of the early 1950s. In the immediate years that followed, leaders in otolaryngology greatly improved their training programs by adding general surgery as a prerequisite, increasing the total length of training to 4 years, later to 5, and finally to 6 years. Looking back, one could easily make the case that Dr. Martin was the tour de force behind this renaissance in otolaryngology. Things really did change.

During this same period, the Society of Head and Neck Surgeons (SHNS) was founded by Dr. Martin and his trainees exclusively for well-trained surgeons. Perhaps the greatest blunder made by the leaders at that time was limiting membership to those certified by the American Board of Surgery. Many years later, this requirement was dropped, and today the roster of this society includes general surgeons, plastic surgeons, otolaryngologists, ra- diotherapists, chemotherapists, pathologists, and some others. Hindsight being what it is, the fault at that time was poor long-range planning. As otolaryngologists received better training in general surgical principles and special training in head and neck oncology, they also desired a forum to share and exchange information. This rigid qualification, required for membership in the SHNS, was directly responsible for the birth of the American Society for Head and Neck Surgery (AWNS) which was organized with the same requirements for membership, save for the need to be certified in general surgery [I]. Dr. Frank Marchetta [2], in his 1986 presidential address, stated it well when he said, “Ani- mosities which promoted this action are still deepseated in some members of both societies.”

During the following 10 years (the 196Os), there was little change in the political scene as each society attempt- ed to outpace the other. The disciples of Dr. Martin moved to cities all over the United States and actually began to train young otolaryngologists when they assisted the senior surgeons. In some instances, Martin’s surgeons joined departments of otolaryngology because they were the source of patient referrals.

In most surgical departments, head and neck surgery was a stepchild. Furthermore, the SHNS made little or no effort to recognize otolaryngologists, even though a

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few by then were also highly skilled surgical head and neck oncologists. As a result, the struggle for national recognition continued between the two societies; mem- berships in each increased, and each presented outstand- ing but individual annual scientific programs. Fortunate- ly, during this time period, both societies appointed educational and training committees because it was recognized that technology and scientific innovation were changing rapidly, even though the political climate between the two groups and the three parent boards re- mained unchanged.

The first visible break in the societal escutcheons was caused by Harry Southwick, president of the SHNS in 1965. In 1969, he was chairman of the education and training committee, At that time, I was the president- elect of the society. Since I was the first president to come up through the ranks from secretary, I knew of all the early machinations and, of course, recognized the political importance of the ASHNS. I, also, remember an admonition made to me by D. M. Searle at the time we were forming the society: “The future of any organization is uncertain until it has passed the tenth year.” Most members of the ASHNS welcomed the meeting that Southwick called on March 14, 1970, at which the presidents and secretaries of the American Boards of Surgery and Otolaryngology and the two societies met to discuss the feasibility of a mutual approach to the training of the head and neck surgeon.

favored a tentative liaison with the SHNS because it seemed obvious that collaboration would accelerate the growth of both societies and place both in a stronger position to deal with the hierarchy of the American boards. Two significant motions were passed at that annual meeting: first, that the specific recommendations and resolutions of the Southwick report would not be accepted, and second, that the ASHNS wished to empha- size its desire to continue discussions in the spirit of coop eration with any group interested in furthering progres- sive objectives in head and neck surgery. I never did give my presidential address, which I had entitled the “State- ment of Hope,” and so I withdrew its publication. The Southwick report was tabled. However, Dr. Beal’s position paper was published in the Annals of Surgery [3]. Meanwhile, I completed my term as president frustrated, having had such great expectations. I went out of office like a puff of smoke disappears on a windy day.

The enthusiasm and hope engendered at that meeting was contagious. Resolutions were drafted to be presented to all three boards for approval. It was naively believed that the boards would work out some mechanism to su- pervise joint programs and eventually issue a certificate of highly recognized proficiency in head and neck oncology. This historical meeting of the two societies and board presidents has been referred to as the Southwick Meeting and Report [I]. All the participants left excited and in- spired. We had all recognized that it was foolish to have two societies in American medicine dedicated to the same purpose. Former president of the American College of Surgeons John Beal announced that he would immediate- ly submit our resolutions to the Annals of Surgery so that this new era of cooperation would be recorded and made known throughout the world. I was going to include the Southwick report and plan in my presidential address. In the meantime, however, a new layer of bureaucracy had been form&, the American Board of Medical Specialties had replaced the former advisory medical specialty board. One day, prior to the ASHNS annual meeting, I took the Southwick report to. our council meeting. To my dismay, my presentation set off a 3-hour heated discussion.

However, during the 10 years that followed, the new joint council actually did change some things. Five suc- cessfully combined scientific meetings were held between 1972 and 1985. Our joint ad hoc committees in postgraduate training, relative value, rehabilitation, education, and liaison with the National Cancer Institute and the American College of Surgeons met frequently and helped strengthen the fragile thread connecting our two societies until it became an actual bond of mutual recognition and surprisingly strong admiration on both sides. Movers, at this time, were Drs. Richard Jesse, EIliot Strong, and Joseph Ogura.

Perhaps my youth or my eagerness to cooperate with the SHNS polarized our comradery. Before this meeting adjourned, it was recommended, among other things, that the incoming president appoint new representatives to the next council meeting. My political mistake had been in pushing too soon and, perhaps, too hard to fulfill the hope that I had always held for our society and the SHNS as well. I had for some time, and quite vocally,

During this same decade, amalgamation was frequently discussed and actually voted upon by the SHNS. The ASHNS president, at that time, elected not to bring it to a vote since, by the constitution, only one-third nay votes would block any amendment. He was certain, by the many letters he had received, that amalgamation would not pass. Important senior members, remembering well the old hurts, added fuel to that particular bonfire. One letter stated that amalgamation would be a disaster. One influential member announced that if amalgamation went through, he would personally start another head and neck society. Nevertheless, the joint council of the SHNS and the ASHNS became formalized in 1974 as the Joint Council for Approval of Advanced Training in Head and Neck Oncologic Surgery. Members continued to work assiduously under the chair of Dr. Lore, and by 1983, had developed training programs in 14 medical centers throughout the United States. All had been site-visited by the Joint Council and all had met the requirements necessary for sanctioning of advanced fellowship training. Since that time, 60 surgeons have completed training in these programs and have received diplomas from the Joint Council.

Last month I attended the first director’s meeting of the now 16 approved programs. Many of the program directors are chairs of university academic departments, but some are young surgeons who have completed advanced head and neck training and are, of course, members of one or both of the societies. This core of highly trained, academically inclined surgeons, as I see it today,

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is where our strength is for tomorrow; the success of their programs demonstrates that a true change has taken place in our small discipline that speaks well for the future. As often said by Sir William Osler, “Change is constant and happy are those who can change with it” M.

While many surgeons were organizing, disorganizing, and politicking, trying to fight crosscurrent trends in the mainstreams of head and neck surgery, a unique commodity was being refined with great precision and is now in the marketplace; young, no more than 10 years old. As does a piece of good leather become soft, stylized, and valuable with polishing, so has this commodity: the well- trained surgical head and neck oncologist becomes out- standing with intelligent processing. The Joint Council, at least for the next decade or more, will largely determine how American medicine manages cancers of the head and neck. There will, of course, be further refinements, especially in basic and clinical research, and substantia- tion of methods and materials by strict peer review will be mandatory. The new generations of head and neck surgeons should accomplish much, and our two societies will be proud to have spawned them.

Enough of the organizational changes that have taken place over the past 30 years. Let us go on to the future perspectives. I have already commented on the new technology now available to diagnose, treat, and render a continuum of care. These improvements or changes have far outpaced the political changes in medicine; most any historical review will admit this. Diagnoses should be easier and arrived at earlier with the glut of new scanners, infusion systems, digital subtraction machines, better miniaturized optics, and user-friendly computers. While surgery continues to predominate as the treatment of choice for most head and neck cancers, it is possible in the near future that medical treatment might become better. Consequently, present and future trainees should be required to understand medical oncology and participate in decision-making when patient treatment is first outlined. A good academic understanding as to what can be ex- pected from any selected treatment should be required so a trainee can competently monitor its course if necessary. Trainees also should be well versed in old therapeutic techniques; many aspects have renewed application. For example, Martin Lecturer Dr. Milton Edgerton [5] has reminded us that the former Mob’s treatment has been modiied into the Tromavitch fresh-tissue technique us- ing local anesthetic for the zinc chloride fixative. This procedure has been beneficial not only at our institution, but also in other cancer centers where it effectively con- trols skin cancers of the nasal alar, auricle of the ear, and orbital and orbicular canthi and commissures. The latest radiation techniques that use hyperthermia, with intersti- tial and intraoperative applications, must be an integral part of modern training. Exploding advances have been made in microvascular reconstructive technqiues for transferring muscle and bone. If experience in this area is not available in an advanced training program, the program director must make arrangements for his fellows to get it at an institution where these techniques are fre-

quently used and taught. In my opinion, it is only a matter of time before every one of our 16 Joint Council training centers will include these particularly important procedures in its head and neck program. It should not be important whether or not these procedures are performed by an experienced hand surgeon, plastic surgeon, general surgeon, otolaryngologist, or neuro-otologist. Of importance is that experience in the use of these techniques should be available in all approved head and neck training programs. This is, of course, true for compression plate use and skull base surgery techniques.

Research training should be mandatory. Keeping abreast of recent developments is vital. For instance, ex- citing research is now ongoing to improve reconstruction techniques of osseous defects. Preliminary results at my own institution indicate it may soon be possible to grow new bone to fill the heinous defects that we leave behind after our extirpative surgery [Constantine PD: personal communication]. I find I can easily envision a time when stereoscopic skull and mandibular defects will be studied so bony reconstruction can be visualized and a plan pro- posed from a computerized data base. A surgeon will then be able to stimulate bony points so that new bone growth will close these defects with acceptable cosmetic results.

Because changes are also ongoing in general surgery and anesthesiology, head and neck trainees must understand all intraoperative monitoring devices, critical patient care life-support systems, and the impressive phar- macopeia available today.

Some institutions have become flap-happy. The newer flaps, the myocutaneous, the osseomyocutaneous, and the microvascular, are all the results of advances recently documented and dropped into the pipeline for the most part by plastic surgeons, but there remain many unan- swered questions. For instance, has the myocutaneous pectoralis flap completely replaced the old workhorse bipedicle tube flap and the Bakamjian flap? Will the microvascular recti or microvascular forearm flaps re- place all methods of intraoral reconstruction? Will the osseomyocutaneous tibia or scapular flap be the best for mandibular repair and stand the test of time? It will become important in the next decade to establish which flap or flaps are best suited for which specific situation. I am somewhat embarrassed to remember an article of mine published in 1969, whereby I classified flaps and grafts according to arterial blood supply [a. How naive I was. All were random flaps, and to this day, I wonder why I didn’t consider the muscle’s blood supply as a nutrition- al source for these flaps. Opportunities to study the latest in reconstructive techniques must be easily available if modernization of head and neck cancer care is to continue, be it at a university or in a community hospital setting. As Dr. Martin might say, “Do not compromise with excellence. It must be provided.” Excellence is a continuum in that what was excellent yesterday may not be so today.

Dr. Lore [7] has written and lectured extensively about “dabblers.” He defines even further and classifies hospitals that perform only four to five major head and neck operations per year as “dabblice,” and further chas-

DO THINGS REALLY CHANGE?


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tises organized medicine (our three parent boards and the American Board of Medical Specialties [ABMS]) as “dabblahs” for not being responsive to our pleas for added qualifications. The ABMS, at their recent March meeting, did give time to esoteric discussions on such topics as “Can the Boards Survive?,” “Better Ways to Define Specialties and Credential Individuals,” and “Is the Government Going To Do It For Us?” President Richard Wilbur [8] suggested that specialties should be defined by what specialists do, not by turf nor by the practices of the 1930s. Further, he questioned whether or not subspeciality societies should take over functions of the larger societies. Interestingly, the American Council of Graduate Medical Education, at their meeting 1 month earlier, discussed accreditation without certification and approved in principle accreditation of subspeciality programs. (A joint conference with the ABMS on this subject took place on June 11, 1989.) Keynote speaker, Rosemary Stevens [9], stressed the need to review medical and professional responsibilities and rethink the defi- nition of a specialty. (It is not just a board.) Of special interest to us was a report from one of the discussion groups which suggested that fellowships developed in medical centers could be accredited even before there was a certificate.

But back to the dabblers. They come from all recog- nixed disciplines: general surgery, otolaryngology, plastic surgery, and even oral surgery. Occasionally, they are dentists or primary care physicians. Often, they are surgeons who undertake poorly planned biopsy (incisional or excisional) nodal procedures or even unnecessary laryn- goscopies. I refer to these operators as creamers. They take the cream-do easy surgery-and once they are in over their heads, they refer to one of us. In time, these creamers will be bleached out of the system by litigation or by governmental regulations which, as you know, are multiplying daily. Perhaps the increasing wave of con- sumerism, patients shopping intelligently for services and viewing excellence as the standard not the exception, will help to eliminate this particular long-standing problem. In the meantime, however, inadequately trained surgeons are a grave problem to patients and to those of us who perform at a high level of competency. To protect not only patients but also our 30-year vested interest in this rela- tively small and complex field, we should not permit the continued erosion of our long-term standards of excellence and dedication of purpose by inaction. While we still hope that organized medicine will take heed and recognixe what we have done and what we wish to do, from long personal experience with this problem, I sus- pect that our three “parents” will still look upon the problem of dabblers as low priority.

Otolaryngology is still trying for an official name change. Surgery is talking about rotating all surgical residents for a short period through a head and neck service if possible. Plastic surgery’s main concerns are apparently the use of the term plastic by other disciplines and the encroachment on the liposuckers by others. Oral surgeons continue to pressure some medical schools to give a combined DDS-MD degree before the oral surgi-

cal board examination is taken; where this will lead is only conjecture. I had thought that this particular issue had been put to death years ago. Many situations really have not changed at all.

Let us return to the well-trained head and neck surgeon. Shouldn’t we push forth with our own particular strengths that have been well established and well based on excellence? Although we now have 16 superior programs for the training of young men and women in this challenging area, it is essential that we take the next step and acknowledge that these programs are centers of excellence, and we should continue to look for others that can be approved by our Joint Council. We must act now before it is mandated by our very big Uncle Sam. Today5 society, and particularly the medical community, is driv- en by the bottom line and consumer desires. John Nais- bitt’s nationwide bestseller Meg&ends [ZO] has outlined 10 new directions that have transformed our lives today. If only onehalf of his forecasts come true (several of his predictions already are facts), we shall be well into an historical era comparable to the industrial revolution. One common denominator of these megatrends is the consumer. We must address him directly and define our purpose and qualifications unequivocally. Believe me, we may better serve and be served with a regional approach rather than with the divisive and destructive turf battles that plague our medical bureaucracy and tarnish society’s perception of its medical community.

Although we may be close to obtaining added qualifications in head and neck oncology, close is not good enough if one recognizes the dynamic forces driving the medical profession today. Multiple attempts by our Joint Council to seek credentialing from our parent boards have been rebuffed, the most recent being the Articles of Agreement prepared by Drs. Strong and Lore.

Further, it appears that organized medicine has lost much of its influence and prestige, as seven state legislative bodies are attempting to pass litigation preventing any kind of subspecialty listing under approved boards, but allowing the listing of boards not approved by the ABMS [Secretary for legislative affairs, AAOHN: personal communication].* Remember, there are only 23 ABMS-approved boards and 63 unapproved boards. If this movement becomes law, subspecialty societies would have no recourse but to accredit themselves! Strange times will be upon us if the most competent surgical oncologists, all board certified by otolaryngology, general surgery, or plastic surgery, have to form an unapproved board in order to be paid by the government and recog- nixed by the consumer as competent. Sometimes an illogical problem is solved by an illogical solution, so in this regard I agree with Richard Farrior, president-elect of the American Academy of Otolaryngology-Head and Neck Surgery, who, while discussing the dilemma of added qualifications in a recent address [I 11, said that “alter- nate boards may become necessary for all manner of reasons-from academic and legal to marketing and eco- nomic.”

* California, Florida, Hawaii, Maryland, Miiuri, Ohio, and Texas.

Isn’t it about time that we take the initiative and come up with our own strategy for our future? To do this we have to work together, and we must support each other as well as the concept.

Let us now move from the abstract to the actual by considering the following items which might be included in any strategic 5-year plan: (1) Form an ad hoc select or steering committee of 12 members, 4 from each society’s past presidents and 2 from each society’s present or past council. (2) Develop and agree (both councils) upon a charge to the select committee; that is, a detailed mechanism for a phased-in merger of the two societies, with a new name suggested such as the American Society of Head and Neck Surgeons, the Society of American Head and Neck Surgeons, or the American Society of Head and Neck Oncologists. (3) Formulate a plan to promote and credential Centers of Excellence in Head and Neck Oncology within univer- sities and community hospitals. (4) Begin feasibility studies to document, recognize, and credential excellence in head and neck oncology for qualifications or certification. (5) Keep all parent boards (general surgery, otolaryngology, plastic surgery), the ABMS, the residency review committees, the American Medical Association, the American College of Surgeons, and the Health Care Financing Administration informed of intentions and progress.

(6) Have an alternative plan in place to form an Ameri- can Board of Surgical Head and Neck Oncology.

I know many of you feel as I do, and I hope I have convinced others that action is not elective. The question is not whether or not we should do something but when and how? Let us hear from you. Come up with a concrete, viable, phased plan and things really will change!

REFERENCES 1. Sisson GA. The head and neck story. The American Society of Head and Neck Surgery. Chicago: Kascot Media, 1983. 2. Marchetta FC. Head and neck surgery: past, present and future. Am J Surg 1986; 152: 342-4. 3. Beal JM. The role of a regional surgical society. Arch Surg 1973; 107: 129-31. 4. House HP. The educational process. ORL J Gtolaryngol Relat Spec 1978; 86: 16-9. 5. Edgerton MT. Advanced basal cancer: prognosis and therapeutic philosophy. Am J Surg 1982; 144: 392-400. 6. Sin GA, Goldstein JC. Flaps and grafts in head and neck surgery. Arch Gtolaryngol 1970; 92: 599-610. 7. Lore JM Jr. Dabbling in head and neck oncology (a plea for added qualilications). Arch Gtolaryngol Head Neck Surg 1987; 113: 1165-8. 8. Wilbur RS. Should speciality societies survive? ABMS Record 1989; 2 March: 7. 9. Stevens R. Can the boards survive? ABMS Record 1989; March: 1. 10. Naisbitt J. Megatrends. New York Warner Books, 1982. 11. Farrior R. Address to Southern Section of Triological Society for 1989 (ii press).


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